Name _______________________________________________

Address ______________________________________________

Phone ______________________________________________

E-mail ______________________________________________

Information on others registering with this payment:

Name _______________________________________________

Address ______________________________________________

Phone ______________________________________________

E-mail ______________________________________________

If additional registrations are included, please write additional information on the back of this form. Thank you.

Symposium Pin ($5/pin) ……………………………………… $_________

Registration Fee  $40 ........................................................... $_________

Please enclose a check payable to ABNC to cover total cost … $ _________

Mail this form and your check to:

Butterfly Symposium, 100 Main Street, Athol, Ma 01331